Citation: Chen Li v. Definity Insurance Company, 2026 ONLAT 24-012909/AABS

Licence Appeal Tribunal File Number: 24-012909/AABS

In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.

Between:

Ruo Chen Li

Applicant

and

Definity Insurance Company

Respondent

DECISION

ADJUDICATOR: John Mazzilli

APPEARANCES:

For the Applicant: Sareena Samra, Counsel

For the Respondent: Domenic Nicassio, Counsel

HEARD: By way of written submission

OVERVIEW

1Ruo Chen Li, (“the applicant”), was involved in an automobile accident on October 10, 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by Definity Insurance Company (“the respondent”) and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2The applicant has been deemed catastrophically impaired in accordance with Criterion 7 & 8 of the Schedule. In addition, the applicant’s submissions inform that he is currently operating under the care of a litigation guardian as he is elderly and confused.

ISSUES

3The issues in dispute are:

i. Is the applicant entitled to $5,583.60 for chiropractic services, proposed by Total Recovery Rehab in a treatment plan/OCF-18 (“plan”) dated November 20, 2023?

ii. Is the applicant entitled to $27,579.42 for assistive devices, proposed by Somatic Assessments and Treatment Clinic in a plan dated November 21, 2023?

iii. Is the applicant entitled to $8,339.60 for occupational therapy services, proposed by Total Recovery Rehab Centre in a plan dated October 4, 2024?

iv. Is the applicant entitled to $5,611.22 for behaviour treatment services proposed by Somatic Assessments & Treatment Clinic in a plan dated October 21, 2024?

v. Is the applicant entitled to $7,873.46 for occupational therapy services proposed by Somatic Assessments in a plan dated October 31, 2024?

vi. Is the applicant entitled to $2,425.25 for an Occupational Therapy In-Home Assessment, proposed by Total Recovery in a treatment plan dated October 4, 2024?

vii. Is the applicant entitled to $73,582.10 for accommodation services, submitted on a claim form (OCF-6) dated January 11, 2024?

viii. Is the applicant entitled to $150.00 for ambulance services, submitted on a claim form (OCF-6) dated May 16, 2024?

ix. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

x. Is the applicant entitled to interest on any overdue payment of benefits?

Withdrawn Issues:

4In his written submissions the applicant withdrew issues i., ii., iv., vi., and viii as listed above.

RESULT

5The applicant is not entitled to brokerage fees associated with the OCF-18 dated October 4, 2024, in the amount of $2,872.80.

6The applicant is not entitled to provider travel time for the OCF-18 dated October 4, 2024, for the OCF-18 dated October 31, 2024

7As no benefits are owing, interest is not owing.

8The applicant is not entitled to an award.

ANALYSIS

The disputed plans

9To receive payment for a treatment and assessment plan under sections 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.

$4,309.20 (8, 339.60 less $4,030.40 approved) dated October 4, 2024, for Occupational Therapy Services (“OTS”)

10I find on a balance of probabilities that the applicant is not entitled to brokerage service fees in the amount of $2,872.80 because they are not reasonable and necessary.

11On April 10, 2025, the respondent approved $4,030.40 for OTS for the OCF-18 dated October 4, 2024, however denied provider travel in the amount of $1,436.40 and $2,872.80 for brokerage service fees. On April 10, 2025, the respondent also partially approved the OCF-18 in the amount of $5,735.70 dated October 31, 2024, and denied $2,137.76 for provider travel time. Therefore, for the purposes of these treatment plans, the remaining issues in dispute are brokerage services fees and travel provider travel time.

12The applicant submits that the treatment has been incurred by the applicant and that the plan is reasonable and necessary and that the respondent continues to assess the claim without proper medical denials.

13The respondent argues that it originally denied the plan on the basis that the medical information indicated the applicant had significant cognitive impairment due to dementia and that the medical information it received from the applicant was outdated as a partial disclosure of the applicant’s family doctor’s records was received on June 3, 2025.

14With respect to the brokerage fees, I find that the applicant did not direct me to evidence that would warrant the reasonableness or necessity of the fee. The PSG is clear that the respondent is not liable to pay all administration costs, overhead, and related costs, fees, expenses, charges and surcharges that have the result of increasing the effective hourly rates, or the maximum fees payable for completing forms, beyond what is permitted under the PSG.

15For this reason, I find on a balance of probabilities that the applicant is not entitled to brokerage fees of $2,872.80 because they are not reasonable and necessary.

Provider travel time-OCF-18 dated October 4, 2024, and OCF-18 dated October 31,2024

16I find on a balance of probabilities that the applicant has failed in his onus to prove entitlement to provider travel time.

17Section 15(2)(c) of the Schedule informs that an insurer is not liable to pay medical benefits for transportation expenses other than authorized transportation expenses. Section 3 (1) of the Schedule, defines “authorized transportation expenses” as expenses related to transportation (a) that are authorized by, and calculated by applying the rates set out in the most recent transportation expenses guideline published by the Financial Services Regulatory Authority (“FSRA”) of Ontario, and (b) that unless the insured person sustained a catastrophic impairment as a result of the accident, relate to transportation expenses incurred only after the 50 kilometres of a trip.

18In his reply to submissions the applicant submits that transportation expenses are payable under the Schedule because he has suffered a catastrophic impairment and that the respondent has failed to address the transportation needs as they have provided no medical reasons and continue to assess the claim without proper medical denials.

19The respondent argues that the applicant has failed to articulate any reasons why $2,137.76 in travel time is reasonable and necessary and that the applicant has not advanced any arguments in his submissions. It argues that the travel time from the occupational therapist’s office to the applicant’s home is approximately 15 minutes. It argues that pursuant to s.15(2)(c) the insurer is not liable to pay medical benefits for transportation expenses other than authorized transportation expenses.

20In this case the applicant did not advance arguments that support entitlement to provider travel time, and in accordance with the PSG an insurer is not liable to pay for expenses related to professional services rendered to an insured person that exceed the maximum hourly rates. In addition, as noted above the PSG informs that Insurers are not liable for any administration or other costs, overhead, fees, expenses, charges or surcharges that have the result of increasing the effective hourly rates.

21I find that approving provider travel time would effectively increase the hourly rate of the occupational therapists’ services. For this reason, I find on a balance of probabilities that the applicant is not entitled to provider travel time for the OCF-18 dated October 4, 2024, and for the OCF-18 dated October 31, 2024.

$73,582.10 for accommodation Services

22The applicant submits that the respondent paid the disputed plan for accommodation services on the date the applicant’s hearing submissions were due, however the applicant did not withdraw the issue in dispute in his reply to submissions, and submits that accommodation services were improperly withheld by the respondent which forms the basis of his claim to an award which I will address below in my decision. The respondent’s submissions and the evidence shows that the OCF-6 was approved by the respondent in full on September 10, 2025, which I accept and therefore is not an issue in the dispute for the purposes of this hearing.

Interest

23Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are owing, interest is not owing.

Award

24I find that the applicant is not entitled to an award.

25The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.

26The applicant submits that the accommodation expenses listed in the OCF-6 were improperly withheld by the respondent. He argues that he is vulnerable, and the withholding of the payment has caused ongoing distress to his wellbeing. He argues that the OCF-6 was submitted to the respondent on January 11, 2024, and the respondent improperly withheld this payment demonstrates its stubborn and inflexible behavior.

27The respondent argues that the applicant submitted the OCF-6 approximately four years after the applicant began to incur the expenses for accommodation that were from January 1, 2020, to December 31, 2020 (Extendicare Scarborough) and January 1, 2021, to October 31, 2023 (Tendercare Living Centre). It argues that on February 11, 2024, it requested disclosure of documents from the applicant to assess the applicant’s entitlement. These documents included the OHIP summary form January 1, 2022, CNRs from his family physician from January 1, 2022, the complete residential medical file from Tendercare Nursing Home, and CNRs from treating specialists from January 1, 2022. It argues that many of these requests have yet to be answered by the applicant and some have only been partially produced, which hindered its ability to adjust the file.

28It argues that despite the applicant’s noncompliance with orders of the CCRO it approved the OCF-6 on a good faith basis. It further argues that an OCF-18 was never submitted by the applicant for any of the accommodation expenses. In addition, the respondent argues that the applicant did not advance a fact-specific argument for an award in his particulars filed on April 16, 2025.

29I find that the applicant is not entitled to an award because the respondent’s behavior in adjusting the file does not lead me to conclude that it acted imprudent, stubborn, inflexible in its adjustment of the file, based on the information it was provided by the applicant.

30It is evident to me that the applicant did not submit an OCF-18 for the accommodation invoices, and the applicant did not request payment for accommodation services that were incurred approximately four years prior to submitting the OCF-6. It is also evident that the applicant failed to produce documents in accordance with the CCRO causing prejudice to the respondent’s ability to adjust the file. In addition, the respondent further sought production of these documents by way of motion on May 26, 2025. The Motion hearing adjudicator ultimately found that these documents were already order produceable and denied the respondent’s request, further supporting the respondent’s position that the applicant hindered its ability to adjust the file.

31In my view the respondent demonstrated good faith by requesting documents it required to adjust the file that had not been produced by the applicant, hindering its ability to adjust the file. I find that the applicant’s request for an award denied.

ORDER

32It is ordered that:

i. The applicant is not entitled to brokerage fees associated with the OCF-18 dated October 4, 2024, in the amount of $2,872.80.

ii. The applicant is not entitled to provider travel time for the OCF-18 dated October 4, 2024, and for the OCF-18 dated October 31, 2024

iii. As no benefits are owing, interest is not owing.

iv. The applicant is not entitled to an award.